Forms

General Forms

• File

  Non Discrimination Notice
• File

  Non Discrimination Notice - Spanish
• File

  Advanced Directives
• File

  Interpreter Languages
• File

  Florida Top 15 Taglines
• File

  Disclosure for Out-of-Network Benefits
• File

  Patient Disclosure of Information
• File

  Pre-Anesthesia Assessment
• File

  Right to Receive a Good Faith Estimate of Expected Charges
• File

  Notice Regarding Patient Protections Against Surprise Billing
• File

  Patient Privacy Notice - Spanish
• File

  Patient Privacy Notice - English

Florida Transparency Bill

• File

  Financial Policy
• File

  Financial Verification Form

Services may be provided by other healthcare providers who may bill separately.

Riverside Anesthesia Services
P. O. Box 639610
Cincinnati, OH 45263-9610
(866) 631-7890

Privacy Notice and Patient Rights

• File

  Privacy Notice
• File

  Patient Bill of Rights

Ownership

• File

  Disclosure of Ownership

Patient Forms

• File

  Pre-procedure Information